The proposal's objectives and aims are to: 1) assess whether patients receiving coronary artery bypass graft surgery (CABGs) and total hip replacement (THR) from experienced continuous quality improvement/total quality management (CQI/TQM) hospitals do better (i.e., superior clinical outcomes, functional health status, satisfaction, and lower costs) than those which are much less involved or not at all involved in CQI/TQM (adjusting for relevant co-variates); 2) assess whether patients receiving cue from non-CQI/TQM hospitals but where CABGs and THR caregivers have received specific CQI/TQM training do better (i.e., as defined above) than non-CQI/TQM hospitals where the caregivers have not been systematically exposed to such CQI/TQM training (adjusting for relevant co-variates); 3) examine differences in the costs of treatment for CABGs and THR patients in the three study conditions - experienced CQI/TQM sites, the non-CQI/TQM sites where caregivers receive systematic education and training, and the non-CQI/TQM sites receiving no such education or training; 4) measure the costs of implementing the CQI/TQM approach in the mature sites for purposes of calculating the relative cost/benefit for patients receiving care from these sites relative to the other sites; and 5) document the specific interventions and activities undertaken by the study hospitals to improve outcomes of care for CABGs and THR. A prospective comparative cohort of a minimum of 3200 CABGs patients and 1600 THR patients will be examined - one-half of whom have received care from hospitals mature in their use of CQI/TQM and one-half of whom have received care from hospitals with little or no CQI/TQM experience. Data on severity, clinical outcomes, functional health status, patient satisfaction, and costs will be collected at relevant points including baseline, discharge, six months post discharge and 12 months post discharge. Half of the non-CQI/TQM hospital caregivers will be randomly assigned to a structured CQI/TQM educational/training intervention, and half will receive no such intervention. Comparisons of patient outcomes between these two conditions will be made on the variables noted above. Appropriate multivariate models will be used to analyze the data taking into account relevant co-variates and hospital effect.. The findings will provide important information on the ability of CQI/TQM to affect clinical and related outcomes of care and on the specific processes that may account for whatever effects that may be found.